When China suddenly scrapped onerous zero-COVID measures in December, the country wasn't ready for a massive onslaught of cases.

Hospitals turned away ambulances, crematoriums burned bodies around the clock, and relatives hauled dead loved ones to warehouses for lack of storage space.

Chinese state media claimed the decision to open up was based on "scientific analysis and shrewd calculation," and "by no means impulsive." But in reality, China's ruling Communist Party ignored repeated efforts by top medical experts to kickstart exit plans until it was too late, The Associated Press found.

Instead, the reopening came suddenly at the onset of winter, when the virus spreads most easily. Many older people weren't vaccinated, pharmacies lacked antivirals, and hospitals didn't have adequate supplies or staff leading to as many as hundreds of thousands of deaths that could have been avoided, according to academic modelling, more than 20 interviews with current and former Chinese Centre for Disease Control and Prevention employees, experts and government advisors, and internal reports and directives obtained by the AP.

"If they had a real plan to exit earlier, so many things could have been avoided," said Zhang Zuo-Feng, an epidemiologist at the University of California, Los Angeles. "Many deaths could have been prevented."

For two years, China stood out for its tough but successful controls against the virus, credited with saving millions of lives as other countries struggled with stop-and-start lockdowns. But with the emergence of the highly infectious omicron variant last year, many of China's top medical experts and officials worried zero-COVID was unsustainable.

In late 2021, China's leaders began discussing how to lift restrictions. As early as March 2022, top medical experts submitted detailed proposals to prepare for a gradual exit to the State Council, China's cabinet.

But discussions were silenced after an outbreak the same month in Shanghai, which prompted Chinese leader Xi Jinping to lock the city down. Zero-COVID had become a point of national pride, and Beijing's crackdown on dissent under Xi had made scientists reluctant to speak out against the party line.

By the time the Shanghai outbreak was under control, China was months away from the 20th Party Congress, the country's most important political meeting in a decade, making reopening politically difficult. So the country stuck to mass testing and quarantining millions of people, even as omicron evaded increasingly draconian controls.

Unrest began to simmer, with demonstrations, factory riots, and shuttered businesses. The pressure mounted until the authorities suddenly yielded, allowing the virus to sweep the country with no warning and with deadly consequence.

Experts estimate that many hundreds of thousands of people, perhaps millions, may have died in China's wave of COVID far higher than the official toll of under 90,000, but still a much lower death rate than in Western countries. However, 200,000 to 300,000 deaths could have been prevented if the country was better vaccinated and stocked with antivirals, according to modelling by the University of Hong Kong and scientist estimates. Some scientists think even more lives could have been saved.

"It wasn't a sound public health decision at all," said a China CDC official, declining to be named to speak candidly on a sensitive matter. "It's absolutely bad timing this was not a prepared opening."

Plans derailed

Toward the end of 2021, many public health experts and leaders began thinking about how to exit from the zero-COVID policy. The less lethal but far more infectious omicron made curbing COVID-19 harder and the risks of its spread lower, and nearby Korea, Japan and Singapore were all loosening controls.

That winter, the State Council appointed public health experts to a new committee tasked with reviewing COVID-19 controls, which submitted a report in March 2022, four people with knowledge of it said. The existence of the document is being reported for the first time by the AP.

It concluded it was time for China to begin preparations for a possible reopening. It ran over 100 pages long and included detailed proposals to boost China's stalling vaccination campaign, increase ICU bed capacity, stock up on antivirals, and order patients with mild COVID-19 symptoms to stay at home, one of the people said. It also included a proposal to designate Hainan, a tropical island in the country's south, as a pilot zone to experiment with relaxing controls.

But then things began going awry.

A chaotic, deadly outbreak in Hong Kong alarmed Beijing. Then in March, the virus began spreading in Shanghai, China's cosmopolitan finance hub.

Initially, Shanghai took a light approach with targeted lockdowns sealing individual buildings a pioneering strategy led by doctor Zhang Wenhong, who had been openly calling on the government to prepare to reopen. But soon, officials in neighbouring provinces complained they were seeing cases from Shanghai and asked the central leadership to lock the city down, according to three people familiar with the matter.

China CDC contact tracing reports obtained by the AP show that a nearby province was detecting dozens of COVID-19 cases by early March, all from Shanghai. Provincial officials argued that they lacked Shanghai's medical resources and capacity to trace the virus, risking its spread to the entire country before China was ready.

At the same time, China's flagging vaccination rate for older residents and the deaths in Hong Kong spooked authorities, as did reports of long COVID-19 abroad.

When Shanghai failed to get control of the virus, the top leadership stepped in. Partial lockdowns in Shanghai were announced in late March. On April 2, then-Vice Premier Sun Chunlan, a top official known widely as the "COVID czar," travelled there to oversee a total lockdown.

"They lost their nerve," said an expert in regular contact with Chinese health officials.

Shanghai was ill-prepared. Residents exploded in anger online, complaining of hunger and spotty supplies. But Beijing made it clear that the lockdown would continue.

"Resolutely uphold zero-COVID," an editorial in the state-run People's Daily said. "Persistence is victory," said Xi.

Keeping silence

After Shanghai locked down, Chinese public health experts stopped speaking publicly about preparing for an exit. None dared openly challenge a policy supported by Xi. Some experts were blacklisted from Chinese media, one told the AP.

"Anybody who wanted to say something that is different from the official narrative was basically just silenced," the blacklisted expert said.

In early April, China's State Council leaked a letter from the European Chamber of Commerce urging relaxation of zero-COVID controls. Council officials wanted to spark debate but didn't feel empowered to raise the issue themselves, according to a person directly familiar with the matter.

The State Council's information office did not respond to a fax requesting comment.

Gao Fu, then head of the China CDC, also hinted at the need to prepare for an exit. At a mid-April internal panel discussion recently made public by the Beijing-based Centre for China and Globalisation think tank, Gao was quoted as saying "omicron is not that dangerous," that there were public discussions on whether zero-COVID needed to be adjusted, and that they "hope to reach a consensus as soon as possible."

Weeks later, at a private event at the German Embassy in Beijing, Gao agreed with foreign experts urging China to plan a reopening and then strode off the stage, according to three attendees who declined to be named because they weren't authorised to speak to the press. Gao did not respond to an email requesting comment.

There were also hints that opinions differed high in the party.

In private meetings with Western business chambers in May, then-Premier Li Keqiang, who was head of the State Council and the party's No. 2 official at the time, appeared sympathetic to complaints about how zero-COVID was crushing the economy, according to a participant and another briefed on the meetings.

It was a stark contrast with pre-recorded remarks from Xi that listed defeating COVID as the top priority. But under Xi, China's most authoritarian leader in decades, Li was powerless, analysts say.

Public health experts split into camps. Those who thought zero-COVID unsustainable like Gao and Zhang, the Shanghai doctor fell silent. But Liang Wannian, then head of the central government's expert working group on COVID-19, kept vocally advocating for zero-COVID as a way to defeat the virus. Though Liang has a doctorate in epidemiology, he is sometimes accused of pushing the party line rather than science-driven policies.

"He knows what Xi wants to hear," said Ray Yip, the founding head of the United States CDC office in China.

Liang shot down suggestions for reopening in internal meetings in January and May of 2022, Yip said, making it difficult for others to suggest preparations for an exit. Liang did not respond to an email requesting comment.

Health authorities also knew that once China reopened, there would be no going back. Some were spooked by unclear data, long COVID and the chance of deadlier strains, leaving them wracked with uncertainty.

"Every day, we were flooded with oceans of unverified data," said a China CDC official. "Every week we heard about new variants. Yes, we should find a way out of zero-COVID, but when and how?"

Authorities may also have been waiting for the virus to weaken further or for new, more effective, Chinese-developed mRNA vaccines.

"They didn't have a sense of urgency," said Zhu Hongshen, a postdoctoral fellow studying China's zero-COVID policy at the University of Pennsylvania. "They thought they could optimize the whole process, they thought they had time."

The Shanghai lockdown stretched from an expected eight days to two months. By the time Shanghai opened back up, it was just months away from China's pivotal 20th Party Congress, where Xi was expected to be confirmed for a controversial and precedent-breaking third term.

Risking an outbreak was off the table. Though scientists from Beijing, Shanghai and Wuhan wrote internal petitions urging the government to start preparations, they were told to stay silent until the congress was over.

"Everybody waits for the party congress," said one medical expert, declining to be named to comment on a sensitive topic. "There's inevitably a degree of everyone being very cautious."

Increasing pressure

Officials across China took extraordinary measures to stop omicron from spreading.

Tourists were locked into hotels, traders were huddled into indefinite quarantine and many stopped travelling for fear of being stranded far from home. In Inner Mongolia, a state-run ammunition factory forced workers to live in its compound 24 hours a day for weeks on end away from their families, according to Moses Xu, a retired worker.

In brutal lockdowns for over three months in China's far west, residents in Xinjiang starved, while thousands in Tibet marched on the streets, defying orders in a rare protest. Still, officials stuck to their guns, as the government fired those who didn't keep COVID under control.

Yet omicron kept spreading. As the congress approached, authorities began hiding cases and resorting to secret lockdowns and quarantines.

Authorities locked down Zhengzhou, a provincial capital home to over 10 million people, with no public announcement, even though they were reporting only a handful of cases.

They bused some Beijing residents to distant quarantine centers and asked them not to post online about it, one told the AP. Some village officials deliberately underreported the number of COVID-19 cases to give the sense that the virus was under control.

Local governments poured tens of billions of dollars into mass testing and quarantine facilities. From Wuhan to villages in industrial Hebei province, civil servants were pressed into testing or quarantine duty because local governments ran out of money to hire workers.

At the Congress in mid-October, top officials differing with Xi were sidelined. Instead, six loyalists followed Xi onstage in a new leadership lineup, signalling his total domination of the party.

Pushing for change

With the congress over, some voices in the public health sector finally piped up.

In an internal document published October 28, obtained by The Associated Press and reported here for the first time, Wu Zunyou, chief epidemiologist at China's CDC, criticised the Beijing city government for excessive COVID controls, saying it had "no scientific basis." He called it a "distortion" of the central government's zero-COVID policy, which risked "intensifying public sentiment and causing social dissatisfaction."

At the same time, he called the virus policies of the central government "absolutely correct."

One former CDC official said Wu felt helpless because he was ordered to advocate for zero-COVID in public, even as he disagreed at times with its excesses in private.

Wu did not respond to an email requesting comment. A person acquainted with Wu confirmed he wrote the internal report.

Another who spoke up was Zhong Nanshan, a doctor renowned for raising the alarm about the original COVID-19 outbreak Wuhan. He wrote twice to Xi personally, telling him that zero-COVID was not sustainable and urging a gradual reopening, said a person acquainted with Zhong.

Business people in finance, trade, and manufacturing concerned about the tanking economy were also lobbying authorities behind the scenes, a government advisor told the AP.

Along with the lobbying, pressure to reopen came from outbreaks flaring up across the country. A November 5 internal notice issued by Beijing health authorities and obtained by the AP called the virus situation "severe."

In early November, Sun, China's top "COVID czar," summoned experts from sectors including health, travel and the economy to discuss adjusting Beijing's virus policies, according to three people with direct knowledge of the meetings. Zhong, the prominent doctor, presented data from Hong Kong showing omicron's low fatality rate after the city's last outbreak, two said.

On November 10, Xi ordered adjustments.

"Adhere to scientific and precise prevention and control," Xi said, according to a state media account, signalling he wanted officials to cut back on extreme measures.

The next day, Beijing announced 20 new measures tweaking restrictions, such as reclassifying risk zones and reducing quarantine times. But at the same time, Xi made clear, China was sticking to zero-COVID.

"Necessary epidemic prevention measures cannot be relaxed," Xi said.

The exit

The government wanted order. Instead, the measures caused chaos.

With conflicting signals from the top, local governments weren't sure whether to lock down or open up. Policies changed by the day.

In Shijiazhuang, the capital of Hebei province, officials cancelled mass testing and opened the city, only to reinstate harsh measures days later. Xi called city officials, instructing them to have measures that were neither too strict nor too soft, according to a person familiar with the matter.

Individual apartments were put under sudden lockdowns that lasted hours or days. The sheer number of tests and cases overwhelmed medical workers. Travel, shopping, and dining ground to a halt, streets emptied, and the wealthy bought one-way plane tickets out of China.

In late November, public frustration boiled over. A deadly apartment fire in China's far west Xinjiang region sparked nationwide protests over locked doors and other virus control measures. Some called on Xi to resign, the most direct challenge to the Communist Party's power since pro-democracy protests in 1989.

Riot police moved in and the protests were swiftly quelled. But behind the scenes, the mood was shifting.

References to "zero-COVID" vanished from government statements. State newswire Xinhua said the pandemic was causing "fatigue, anxiety and tension," and that the cost of controlling it was increasing day by day.

Days after the protests, Sun, the COVID czar, held meetings where she told medical experts the state planned to "walk briskly" out of zero-COVID. Some were struck by how quickly the tone had shifted, with one saying the leadership had become "even more radical" than the experts, according to a retired official.

On December 1, Xi told visiting European Council President Charles Michel that the protests were driven by youth frustrated with the lockdowns, according to a person briefed on Xi's remarks.

"We listen to our people," the person recounted Xi telling Michel.

The final decision was made suddenly, and with little direct input from public health experts, several told the AP.

"None of us expected the 180-degree turn," a government advisor said.

Many in the Chinese government believe the protests accelerated Xi's decision to scrap virus controls entirely, according to three current and former state employees.

"It was the trigger," said one, not identified because they weren't authorized to speak to the media.

On December 6, Xi instructed officials to change COVID-19 controls, Xinhua reported.

The next day, Chinese health authorities announced 10 sweeping measures that effectively scrapped controls, canceling virus test requirements, mandatory centralised quarantine and location-tracking health QR codes. The decision to reopen so suddenly caught the country by surprise.

"Even three days' notice would have been good," said a former China CDC official. "The way this happened was just unbelievable."

Soon, the sick overran emergency wards and patients sprawled on floors. COVID-19 antivirals sold for thousands of dollars a box on the black market.

In just six weeks, about 80 per cent of the country was infected more than a billion people, the China CDC later estimated. But even as deaths mounted, authorities ordered state media to deflect criticism over China's sudden reopening, according to a leaked directive obtained by a former state media journalist and posted online.

"Make a big propaganda push," it ordered. "Counter the false claims levelled by the United States and the West that we were 'forced to open' and hadn't prepared."